Provider Demographics
NPI:1699066084
Name:SUHAIL, JAWARIA T (MD)
Entity type:Individual
Prefix:DR
First Name:JAWARIA
Middle Name:T
Last Name:SUHAIL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 S CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:WENONA
Mailing Address - State:IL
Mailing Address - Zip Code:61377-7526
Mailing Address - Country:US
Mailing Address - Phone:815-853-4402
Mailing Address - Fax:
Practice Address - Street 1:516 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:WENONA
Practice Address - State:IL
Practice Address - Zip Code:61377-7526
Practice Address - Country:US
Practice Address - Phone:815-853-4402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036130616207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400167473OtherMEDICARE PTAN
IL036130616Medicaid